Alzheimer’s Disease

Interested in participating in an Alzheimer’s Disease study?

Fill out the form below to see if you qualify.

First Name*

Last Name*


Phone Number*

Have you ever been diagnosed with Alzheimer’s Disease?
 Yes No

Have you consistently had a problem with memory or thinking?
 Yes No

Have you had a MRI, CT Scan of the head or lumbar puncture done?
 Yes No

-If yes, which one(s)?

-If yes, when (date)?

-If no, are you willing to have done if necessary?
 Yes No

Are you currently taking any medication for memory problems?
 Yes No

Do you have a caregiver or family member that is willing to accompany you to study visits and answers questions?
 Yes No

How did you hear about us? (required)

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